WHO and Cochrane collaboration to accelerate evidence-based public health

Prof Lisa BeroPhoto credit: UCSF

Shobha Shukla and Bobby Ramakant, CNS
The World Health Organization (WHO) has accepted the Cochrane Collaboration, the largest repository of systematic reviews that provides reliable and thorough evidence on healthcare, as a non-governmental agency in "official relations with WHO". This collaboration between the two can potentially accelerate the uptake of evidence-based medicine, health policy and practice. Citizen News Service (CNS) interviewed Professor Lisa A Bero, the key leader in the Cochrane Collaboration who helped make this synergistic two-ways linkage happen in 2011.
Prof Lisa Bero who is committed to the cause of translating science into clinical practice and health policy, serves as the Director of San Francisco branch of the US Cochrane Centre and Co-Chair of Cochrane Collaboration Steering Group. She spoke with CNS at the 22nd Cochrane Colloquium in Hyderabad, India.

The Cochrane Collaboration envisions is to provide a high-quality learning environment to enable contributors to enhance their skills and knowledge effectively to help it achieve its goals of producing evidence; making that evidence accessible; and advocating for evidence; among others. The WHO on the other hand is 'responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options' among other roles. The WHO acknowledges that, "In the 21st century, health is a shared responsibility, involving equitable access to essential care and collective defence against transnational threats and WHO is reforming to be better equipped to address the increasingly complex challenges of the health of populations." Associating with the Cochrane Collaboration is certainly a leap forward. This collaboration between these two agencies is bound to enhance uptake of evidence informed, context-specific, resource-sensitive, culturally compatible and equity promoting recommendations for health policy and practice at the global level.

Prof Bero was happy to note that, "As Cochrane now has an official channel with the WHO, there is better communication at the central level with them, and it has particularly improved in the areas of essential medicines and the guidelines. We have done some training for WHO employees, and this has helped increase their skills, in not only doing reviews themselves, but also in being able to use Cochrane reviews. If that central communication was not there we would not have been able to do all that."

However, she felt that there was need for more communication and training so that they use the reviews in a proper manner, because, “Even when they (WHO) are citing Cochrane reviews, they seem to be missing that next step, when you decide, if it is a strong recommendation. Instead processes usually rely heavily on experts in a particular specialty rather than representatives of those who will have to live with the recommendations or on experts in particular methodological areas.”

“WHO recommendations are often strong based on low confidence in effect estimates. 160/289 (55%) of strong recommendations (from 43 guidelines) were based on low or very low confidence in estimates. Cochrane reviews were rarely the only source of evidence and limited to efficacy of interventions, but were less on harms, implementation, health systems, and environment.”

"It is they (WHO) who set the priorities. WHO has its public health priorities and they tell us (Cochrane Collaboration) that these are the guidelines coming up. So one problem with us is that we cannot produce the reviews fast enough at times. But working around the essential medicines list is a little different because the applications can come in from anybody - countries, WHO partners, companies - and Cochrane can provide systematic reviews about those medicines.”

In fact WHO has requested the Cochrane Collaboration to produce and/or update systematic reviews of essential medicines, including those for children, which are being considered for deletion or addition to the WHO Model Lists of Essential medicines, including preparation of GRADE tables.

Delving upon the challenges in putting science for public health good Prof Bero said that, “There are issues of relevance, sufficient resources and efficient systems and equity. Cochrane is involved more with epidemiology and science part of it. Even if we have got the best evidence, but if we cannot pay for it and if we do not have proper health system structures, we cannot implement it. Very often policy makers get criticized for not using evidence, but this may not be completely under their control all the time.”

Professor Bero conceded that at times evidence-based medicine may not be able to react fast enough to crisis situations like sudden outbreak of diseases where rapid responses are required—like in the case of Ebola outbreak when vaccine and medicine development and roll out had to be very rapid. She was of the opinion that in crisis situations when people are dying, decisions regarding roll out of certain medicines and vaccines may have to take place even in the face of insufficient evidence.

According to her, “Although Evidence Aid is a great example of pulling together reviews relevant to a particular disaster, but basically if the reviews are not there, it cannot be done fast enough. So sometimes rapid response like on Ebola cannot get evidence based medicine. It is my biggest concern that sometimes because it is a crisis situation, we cannot evaluate due to time constraints. But we can still help in such cases by evaluatingit really well as it is being used. Just because it is a crisis it does not mean that it cannot be evaluated.”

Building and strengthening relationships between the two organisations will serve a number of purposes: Advancing the use of evidence to inform healthcare and health policy decision-making, ensuring that reviews are conducted that are directly relevant to low and middle income countries, and building research capacity in low and middle income countries.